Generally, the approach will be a counseling-based approach, but it can be supplemented with the use of sound therapy. What does sound therapy mean? In the experience of tinnitus, generally, your attention will be drawn to the tinnitus because the room is too quiet, so there's too much contrast, and your brain will perceive the tinnitus as the loudest sound because there's nothing to put it into any type of auditory context. Now, counseling can stand by itself; sound therapy is a supplement. Generally, you don't use sound therapy without some measure of counseling, but sound therapy can be more of an immediate relief to patients when it's used because it helps you reduce your awareness of tinnitus. But you have to use it very specifically. You don't want to overwhelm or mask the tinnitus because we can't habituate to an experience if we don't experience it. You have to be able to listen to the tinnitus while simultaneously listening to a therapeutic sound.
Therapeutic sound can be anything that you enjoy. It could be music, it could be nature sounds, it could be broadband noises like fans running, white noise, pink noise, and they're easily obtained through websites and apps and other devices, whatever you would feel comfortable listening to for an extended period of time. Some people like talk radio, so it's truly an individual choice. But that sound that is in use should never be louder than the tinnitus. We want the tinnitus and the sound therapy signal to be at a level where you could direct your attention between both signals.

This is where some people that have done research online will apply sound therapy, but not with the correct guidance. So they're using a very loud level of their sound therapy. That is not going to be effective because again, you don't habituate to something you don't experience. When you turn on your sound therapy, it should be at a very low level that you can hear, but you could also direct your attention back to the tinnitus. Ideally, it should be something that you feel is a pleasant distraction. There are some concerns that using music, because it has an emotional context, could keep you in a more depressed state if the music has emotional content that might be perceived as sad. But certainly, if it's something that you enjoy or gravitate towards, then yes, that is an appropriate use of sound therapy.
When would sound therapy be used? Sound therapy can be used continuously all day to promote a measure of distraction, and I find that it is most effective though when the rooms are very quiet. Let's say you are trying to concentrate on reading an article or doing a task at work. It's good to have your sound therapy playing in the background because it minimizes the contrast of the listening environment so your tinnitus doesn't sound very loud and wouldn't draw your attention. Having something playing lightly in the background is a good choice for a quiet activity.
Let's say it's time for bed and you're getting ready to lie down. Generally, we don't blast loud music when we're trying to fall asleep. So, the room is generally very quiet most of the time. That is when the tinnitus will seem extremely loud. Having a sound generator by the bed or a radio, something that you're using for your sound therapy, play that in order to relax. At that point, you might want to choose a different type of sound therapy. Sound therapy doesn't have to be the same signal all the time. It's there to help you distract and relax, so you can change it in order to meet the needs of the listening environment. At bedtime, maybe you're choosing nature sounds or you're listening to just a white noise to help you drift off to sleep.
Some people do feel that they hear their tinnitus continuously all day. Listening to your sound therapy for eight hours a day, there's no harm in doing that. Listening to it for eight hours while you're sleeping, no harm in doing that. Some people with sound therapy can have what's called residual inhibition. So even when they take away the sound therapy, they have a measure of being unaware of their tinnitus for an extended period of time.
If you have your hearing evaluated and you actually have an audible hearing loss, then we would approach your sound therapy with the use of amplification. Hearing aids can be an appropriate way of assisting patients with tinnitus because ultimately one theory of tinnitus generation is that the brain is receiving less stimulation because the peripheral sensory organs are no longer functioning optimally, and that is leading to the change in hearing.